What is the initial management approach for a patient presenting with symptoms suggestive of os trigonum?

Initial Management of Os Trigonum Syndrome

The initial management approach for a patient presenting with symptoms suggestive of os trigonum should include rest, NSAIDs, and physical therapy for at least 3 months before considering surgical intervention. 1

Clinical Presentation and Diagnosis

Os trigonum syndrome is characterized by:

• Posterior ankle pain exacerbated by plantar flexion
• Commonly seen in ballet dancers, soccer players, and athletes requiring repetitive plantar flexion 2
• Pain typically localized to the posterolateral aspect of the ankle 3
• Pain may be elicited with forced plantar flexion movements

Diagnostic approach:

• Lateral radiographic view of the ankle in maximal plantar flexion to visualize the os trigonum 2
• If radiographs are negative but symptoms persist, MRI may reveal scar tissue behind the posterior talus 2
• Diagnostic confirmation can be achieved by injecting local anesthetic under fluoroscopic control 4

Conservative Management Algorithm

1. First-line treatment (0-3 months):

   • Activity modification and relative rest 1
   • NSAIDs for pain and inflammation control 1
   • Physical therapy focusing on:
     • Range of motion exercises
     • Strengthening of ankle musculature
     • Proprioceptive training 1

2. Second-line treatment:

   • Corticosteroid injection under fluoroscopic guidance if initial measures fail
   • May require a second injection in some cases 4

When to Consider Surgical Intervention

Surgical excision should be considered only when:

• Conservative measures have failed after at least 3 months 1
• Symptoms persist despite activity modification and injections
• Patient has unavoidable plantar flexion requirements due to sport/occupation 2

Important Considerations and Pitfalls

• Timing matters: Patients with symptoms present for less than 2 years before surgery have significantly better outcomes (average AOFAS score of 90 points) compared to those with symptoms for more than 2 years (average score of 78 points) 5

• Associated conditions: Os trigonum syndrome is often associated with flexor hallucis longus tendon pathology, which should be evaluated and addressed 2

• Surgical complications: Sural nerve injury is the main complication of surgical excision (reported in 8 of 41 patients in one study, with half being permanent) 5

• Success of conservative treatment: In one study, 84% of patients responded to corticosteroid injections, with only 16% requiring surgical intervention 4

By following this structured approach to management, most patients with os trigonum syndrome can achieve symptom relief without requiring surgical intervention.